Workplace violence is a serious problem in the healthcare industry. Three-fourths of all workplace violence occurs in a healthcare or social service setting.

• Consider both the likelihood of certain violent acts and the potential impact.

• Review internal records and industry reports for the most common types of violence.

• Train staff in how to handle violent patients and visitors.

A recent Sentinel Event Alert from The Joint Commission (TJC) emphasizes the need to address workplace violence in healthcare settings, noting that the Occupational Safety and Health Administration (OSHA) reports approximately 75% of nearly 25,000 workplace assaults reported annually occur in healthcare and social service settings.

Workers in healthcare settings are four times more likely to be victimized than workers in private industry, TJC notes, with a 20% higher chance of being the victim of workplace violence than other workers.

“Alarmingly, the actual number of violent incidents involving healthcare workers is likely much higher because reporting is voluntary,” according to the alert. “Researchers at Michigan State University estimated that the actual number of reportable injuries caused by workplace violence, according to Michigan state databases, was as much as three times the number reported by the [Bureau of Labor Statistics], which does not record verbal incidents.” (The Sentinel Event Alert is available online at: https://bit.ly/2KPVSzf. See the story in this issue for a summary of recommendations from TJC.)

TJC has several standards that relate directly or indirectly to workplace violence, including Leadership (LD) and Rights and Responsibilities of the Individual (RI) standards that establish the framework for safety and security of all persons in the organization. Provision of Care, Treatment, and Services (PC) standards provide guidance addressing patient assessment and interventions, and Environment of Care (EC) standards address the physical environment and practices that enhance safety.

Consider Likelihood and Impact

Determining the risk of violence in a healthcare setting requires looking at two factors: the likelihood of occurrence and the significance of impact, says Jodi D. Taylor, JD, shareholder with the Baker Donelson law firm in Atlanta.

“It is less likely that an active shooter situation will occur. However, if it does, the significance of that impact is great. It is more likely in a hospital setting that violence will occur from patients, but the impact of that violence is less significant,” she says. “The more likely scenarios — patients with mental illness and cognitive deficiencies, and family members placed in stressful situations, exacerbated by unfavorable outcomes — pose the greatest threats of workplace violence, such as pushing, hitting, spitting, throwing objects, and verbal assaults.”

The most likely risks of workplace violence can be determined by discussions with employees or reviewing OSHA incident logs, and policies should address the most frequent types of violence.

The less likely/big impact scenarios such as an active shooter also must be addressed, she says. Healthcare facilities should have an active shooter plan, train employees on the plan, and hold drills for all employees, she says.

Policies and procedures also must address issues such as weapon carry policies and employee codes of conduct, she says. The hospital also can consider employee assistance programs and wellness programming that focuses on stress relief such as walking programs, healthy lunch incentives, and perhaps even offering chair massages at the office. Efforts like that can help relieve employee stress and reduce the likelihood an employee will engage in a violent act at work.

“It also is critical to train office staff on how to handle patient or visitor aggression, recognizing when the situation is escalating, and implement policies for handling response,” she says. “That may include notifying security and calling law enforcement as necessary.”

More Potentially Violent Patients

Research indicates that the most common characteristic exhibited by perpetrators of workplace violence is altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness, says Barbara E. Hoey, JD, partner with the law firm of Kelley Drye in New York City. One study showed that 29% of shootings in EDs involved patients in police custody, with 11% occurring during escape attempts.

Those numbers are important because hospitals increasingly are providing care for potentially violent individuals, Hoey notes. Resulting injuries often are addressed through the workers’ compensation system rather than lawsuits against the hospital, she says, but the facility still can suffer related losses.

Prevent, Report, React

“We often see employees leaving the facilities after being injured through workplace violence, which carries a significant cost in terms of replacing that skilled employee and bringing that new person into the system,” she says. “These incidents also can turn into union grievances. We represent inner city hospitals, and we see these things all the time because of the population they serve.”

Violence is an unavoidable part of providing healthcare to the public, Hoey says, because many segments of the patient population are prone to violence for various reasons.

Completely avoiding violence in a healthcare setting may be impossible, but organizations can minimize the impact with a three-pronged approach that addresses prevention, reporting, and reaction, she says.

“A risk manager cannot prevent a drug-crazed individual from coming into the hospital and jumping off a stretcher to punch a nurse,” she says. “But you can take preventive steps that lower that risk and lower the potential impact if that event does happen, such as having security guards whose presence either discourages that activity or helps end it before serious harm can occur.”

Male aides in the ED psychiatric unit are another example of how the impact of such events can be minimized, she says. Other precautions include self-locking mechanisms on psychiatric units, and even the ED.

“There are some hospital EDs where they lock the doors after a certain hour and if you show up not looking particularly ill, they’re going to call security before they buzz you in. The security guard might talk to you outside before they let you in,” Hoey says. “There are other controls like security cameras that allow the security department to respond in a timely manner. Even if an act of violence can’t be avoided, you can take the steps to minimize how much your employees are hurt.”

Opportunities to Learn

Encourage employees to report all acts of violence and threats of violence, Hoey says. Every instance of violence is an opportunity to learn what could have been done better, she says.

“Every time someone gets hurt, there are going to be multiple points where people failed,” she says. “When you report it and do a full analysis of what happened, it’s the same as doing an analysis after an adverse event. Who didn’t lock the door? Who wasn’t looking at the security monitor? Why? What else were they doing when they should have been on the monitor and responding to the threat?”

The reaction after the event is the third prong, acting on the reports and analysis to implement changes that could prevent a repeat of the same type of violence, Hoey says. This could involve changes in policy and procedures, environmental upgrades such as new door locks or metal detectors, or even dismissing employees.

Be sure to seek input from employees on the best ways to improve security, not just from security guards or consultants, because the nurses and others most vulnerable to assault are the ones who often can suggest the most practical and effective interventions, Hoey says.

“Like anything, a lot of this comes down to money. Some hospitals have more funding for implementing security strategies than others, but I think any hospital should invest as much as they can in security for their employees and patients,” Hoey says. “Any incidence of violence is a horrible blemish on the reputation of a hospital. The impact of violence in the hospital can be far-reaching, much beyond the initial trauma and financial costs, because doctors and patients have so much choice now in where people get treated.”


• Barbara E. Hoey, JD, Partner, Kelley Drye, New York City. Phone: (212) 808-7628. Email: bhoey@kelleydrye.com.

• Jodi D. Taylor, JD, Shareholder, Baker Donelson, Atlanta. Phone: (404) 589-3413. Email: jtaylor@bakerdonelson.com.